DY3, Q2 October 2017

Data Analytics Enabling

‘Real World’ Clinical Integration

By Al Hammonds, CSSBB, Executive Director

Millennium has launched the next phase of connecting data analytics to the needs of targeted populations. As a result, we are beginning to see progress towards our ultimate goal of enabling integrated care coordination and care transitions.

An example of this progress is recent work by Michele Mercer, Millennium’s Chief Clinical Integration Officer, and our Data Analytics Team. After receiving Medicaid Client data from New York state, the team completed a drill down and matched Primary Care Physicians to Medicaid clients who were admitted to the hospital and/or who received Emergency Department (ED) care that involved sensitive ambulatory conditions. This data resource in turn helped the physicians better address why their patients were going to the ED, and enabled them to implement changes to patient care where possible. Overall, this was a major step toward creating a clinically integrated network by using data to do “real world” clinical integration.

Looking immediately ahead, most of the work that we are doing as a Performing Provider System (PPS) through the Master Participation Agreement (MPA) process with over 100 Partner entities is foundational to establishing a Value Based Payment environment and arrangements. As we continue on the “Value Based Payment Journey,” we look forward to sharing more about the work of our Partner entities around transformation and foundational change.

Community providers and partners recently joined together in the Millennium conference room to collaborate on the next phase of our “Value Based Journey.”

COPD Pilot Launch Will Enable Physicians

to ‘Live’ Value Based Payment  Approach

Dr. Anthony Billittier

By Anthony J. Billittier IV, MD, Chief Medical Officer

Arguably, one of the most important changes Millennium and our Partners will leave behind is transformation of our health care delivery system from a Fee-for-Service to a Value Based Payment (VBP) care model. “Quality” over “quantity” must become our mantra. Doing less instead of more must become our focus. Realistically, making this monumental leap will be challenging before the reimbursement system funding switch flips.

Like many changes in life, until we are directly impacted, the “change” can remain largely conceptual in our minds. Likewise, until the new Master Participation Agreement (MPA) reimbursement requirements take full effect, VBP will likely remain largely “conceptual” in the minds of Primary Care Physicians and others.

VBP education and planning will be important.  However, education and planning alone will not get us across the finish line.  Physicians and our care teams need a real-world opportunity to see, touch and live a VBP approach.  Ideally, this opportunity should be a project of manageable size (pilot) and occur before full-blown financial risk accompanies it. Practice will be important before game day!

A focus on Chronic Obstructive Pulmonary Disease (COPD) in the recently released MPAs offers a chance to dip our collective toes in these new VBP waters.  COPD leads to significant numbers of Potentially Preventable Emergency Department Visits (PPVs); Potentially Preventable Hospital Admissions (PPAs); and Potentially Preventable Readmissions (PPRs); making it low lying fruit. COPD also lends itself to an evidenced-based approach clearly articulated in the GOLD guidelines: (Global Initiative for Chronic Obstructive Lung Disease ).

 Please click on cover at left for pdf of the Pocket Guide.

To that end, Millennium will be ramping up a COPD population health/medical neighborhood pilot with some of our Partners. This multi-pronged effort will include diagnostic standards, care coordination, environmental controls, medications management including medication compliance, etc.  It will need to be guided by population analytics and supported by a Value Based proposition. This tangible effort should be a great learning opportunity for Millennium and especially our Partners.

Patient/Physician Engagement Foundational 

To Successful Value Based Outcomes

By Christine Blidy, Chief Network Officer, DSRIP

As Millennium continues to rapidly move forward on our Value Based Journey, our primary focus is on “Quality Performance” and “Outcomes”.

To provide further incentives for Partners, we have launched regional bonus programs with specific focus on decreasing avoidable Emergency Department and hospital utilization; and on improving the outcomes in quality of care for our vulnerable Behavioral Health population. In addition, the standard Master Participation Agreements (MPAs) that were recently distributed emphasize the importance of Primary Care.  Specifically, the MPAs focus on Medicaid member engagement with Primary Care Physicians who are in our networks to ensure that patients within their practice are coming in for important preventative care, while also ensuring optimal management of their chronic conditions.

The main building block of a Value Based approach is ensuring patients are personally engaged with their healthcare; and that the full spectrum of provider services are integrated and coordinated in a manner that results in high quality care and measurable positive outcomes. Millennium has launched the next phase of connecting data analytics to the needs of targeted populations. As a result, we are beginning to see progress towards our ultimate goal of enabling integrated care management and care transition.

Millennium is very excited about the progress that has been made and the increasing focus on quality outcomes. We look forward to continuing this crucial mission with all of our partners.  

Care Coordination/Transitions of Care Survey Results Providing Strategic Guidance

Michele Mercer

By Michele Mercer, RN, MSHA, Chief Clinical Integration Officer

To view a brief compilation of the survey results, please click on chart above.

Millennium recently distributed a “Care Coordination and Transitions of Care Survey” to our Partners serving Medicaid clients across Western New York in Primary Care, Behavioral Health, Acute Care (Hospital), Health Home and Community-based organizations. The primary goal of this survey was to identify gaps in care coordination and transitions of care in our Partner community. We wanted to obtain this valuable data and feedback prior to launching Millennium’s strategy to deploy a new Care Coordination Support Team made up of two Care Managers (one being a Licensed Professional) and a Clinical Pharmacy Medication Reconciliation Specialist

Effective Care Coordination is a patient-centered model that is vital to ensuring that patients receive the quality care that they need in the right setting. Care Coordination also enables the identification of a patient’s specific social determinants of health, enabling these factors to be addressed through the care coordination process. Ultimately, the objective is for Partners such as Primary Care Physicians to focus on what they do best, while our Care Coordination Support Team addresses any unmet priority social needs a client may have such as lack of transportation; housing issues, and/or the need for behavioral health coordination. To view a brief compilation of the survey results, please click HERE.   In addition to explaining the methods we used to outreach to our Partners and how many organizations responded; responses received are enabling Millennium to fine tune our selection process to ensure we deploy and leverage a high performing team that will meet our Partners’ needs going immediately forward.

Driving Toward Data-Enabled Performance Management

By Jon Phillips, Chief Analytics Officer 

We all realize that the move toward Value Based contracting will be a journey and we will surely encounter bumps in the road. (If this was easy, it would have been done by now!) Our Data Analytics Team at Millennium is working hard to provide our Partners the information they need to allocate their limited resources to improve the quality of care while reducing preventable utilization of high cost emergency room care and hospital admissions. The first step toward Value Based contracting is managing Pay-For-Performance (P4P) fee arrangements. This is how we will use data and analytics to support P4P:

  • Aggregating data across multiple data providers to provide the most complete patient record available in Western New York. Care providers will no longer be limited to an individual provider’s Electronic Medical Record.
  • Providing insights that our care providers can use to identify patients that need to be scheduled for a visit to better manage their chronic conditions and/or provide preventative/wellness services.
  • Providing the most complete picture of gaps in care that the Care Coordinator can use for pre-visit planning to identify what the care team needs to do during the visit to improve patient health and reduce risk.
  • Identifying and stratifying patient risk for unfavorable utilization of health services and develop strategies and care plans to reduce the patient’s risk.
  • Providing standard and ad hoc reports that identify and trend how our contracted care providers and their medical professionals are doing on important Delivery Service Reform Incentive Program key performance indicators (KPIs).
  • Identifying the root causes of unfavorable health outcomes.  We need to understand “why” health outcomes are better or worse. By identifying these factors that affect health outcomes for our patients, we can design processes of care that are likely to provide better patient care and outcomes.

Members of Millennium’s Data Analytics Team include Aaron Thorne, Assistant Information Systems Specialist, iMEDS; Miranda Chia, Business Performance Analyst; Jon Phillips, Chief Analytics Officer; Patrick Gagnon, Enterprise Systems Support Analyst; and  Jordon Rabey, Health Care Analyst.

WNY Behavioral Health and PPS Partners

Take Lead with Local VBP Application

Andrea Wanat

By Andrea J. Wanat, MA, CPP,  Director of Behavioral Health 

To assist Behavioral Health entities across New York state become more prepared for the transition to Value Based Payments, the state has released a request for proposals to support the creation of collaborative entities or networks such as Independent Practice Associations (IPA). The application is due on Nov.,10, 2017; and in Western New York, a collaboration of four entities is leading the charge!


The founding agencies include Best Self Behavioral Health; Endeavor; Horizon Health; and Spectrum Health and Human Services.  An informational meeting was held in June to discuss this innovative collaboration and approximately 80 providers from the Prevention and Treatment fields came together from Millennium’s eight counties (Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, and Wyoming).. The state views these formal collaborations as the way to preserve New York’s Behavioral Health agencies in each Regional Planning Consortium region in the face of the rapidly advancing Value and Risk Based contracting requirements. IPAs can negotiate and contract on behalf of its Network members in a risk-based contracting world, and at the same time, the integration and coordination of services with Affiliate members can also be both maintained and strengthened by the IPA. Stay tuned for more information on this exciting endeavor!

Quick Read: MCC Headlines

ECMC Emergency Department Adds ‘Health Home’ Services

ECMC Medical Minute Features MCC Exec Director Al Hammonds on Key New Role of Patient Navigators

‘Connect 4 U’ Launched to Continue to Move ‘Niagara Community Partnership Project’ Forward

New Resource: Mental Health Triage Tool Training

MCC Team News

Join Our Team!

Care Manager 

Care Manager – Licensed Professional

Clinical Pharmacy Medication Reconciliation Specialist

Welcome to Millennium!

Nicole Aloisio, Care Coordinator Assistant

Julianne Hergenroder, Data Analyst

Julie Lesakowski, Financial Accountant

Allie Nash, Operational Reporting Analyst 

In the Press Click on Photos to Watch/Read Coverage!

Click Here to Watch Millennium’s Aug. 30 Appearance on WBBZ-TV ‘716 DAILY BUZZ

Prime Opportunities Magazine UK: Barbers Will Monitor Your Blood Pressure

WBFO: Haircuts & heart health — Niagara Falls barber shops checking blood pressure 

INTERACTIVE MAP: Where to Find Barber shops and beauty salons offering blood pressure monitoring through the B & B Health Stops initiative 

Business First: Barber offers more than a cut and a shave 

Spectrum News: Niagara Falls barbers offering free blood pressure checks


Buffalo News: WNY effort to address youth mental health,  substance abuse becomes online sensation
Anthony Donalson, right, Youth Peer Mentor at the Mental Health Association of Erie County, and Michele Mercer, Chief Clinical Integration Officer with Millennium Collaborative Care, both helped with the improvements at JustTellOne.org

Buffalo Healthy Living Magazine:  Millennium’s Andrea Wanat with Kirby

Upcoming November 8, 2017 … Click Here to Register



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